HISTORY: 19-year-old male collegiate lacrosse player presented to the training room with abdominal pain, emesis, and gross hematuria following a cross-check to his abdomen during a game one day prior. Symptoms cleared with a negative urine dipstick 48 hours after injury and he was cleared for competition. One week later, he was cross-checked again in the abdomen, resulting in similar symptoms including hematuria, abdominal pain, anorexia, and emesis. He denied significant medical history, denied taking medications, previous trauma, surgeries or smoking. He reported a history of split urinary stream. Symptoms persisted 4 days post injury at which time he was sent to the ER for further evaluation. PHYSICAL EXAM: Gen: No acute distress, well-appearing GU: uncircumcised penis, normal descended testes bilaterally, no mass/hernias, normal phallus, normal epididymis, normal scrotum, urethral meatus normal without blood. Abdomen: no ecchymosis, normal bowel sounds, abdomen tender to palpation in the LUQ, suprapubic area, and left flank. No rigidity, guarding, or organomegaly. DIFFERENTIAL DIAGNOSIS: Bladder wall hematoma/contusion/perforation Renal contusion Splenic injury Ureteral/urethral Injury FINAL/WORKING DIAGNOSIS: Abdominal pain, hematuria, and trace intraperitoneal free fluid status post blunt abdominal trauma without evidence of bladder, ureteral, urethral, or kidney injury TESTS AND RESULTS: CBC and BMP normal Urine analysis moderate blood with >50 RBCs FAST ultrasound - normal CT abdomen/pelvis with contrast - trace intraperitoneal free fluid behind bladder, no bladder injury CT/cystogram- negative for bladder rupture or injury TREATMENT AND OUTCOMES: Urology consulted in the ED and discharged following CT cystogram failed to show organ damage. At one week, he was asymptomatic and had a negative urine dipstick. Urology suggested cystoscopy if hematuria re-occurred. He was cleared for gradual return to play and recommended to use abdominal guarding in the future. While hematuria following abdominal trauma is not rare, subsequent free fluid spurs questions of whether there were predisposing factors (i.e. stricture) or if an acute injury resulted in the clinical and diagnostic findings. This is an unusual problem following such an injury and a unique workup with questions on his safe return to play.
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